How insurance networks fit together and pay claims leaves some dentists befuddled
The merger of three networks and understanding what it means for a business to be a network aggregator has left some dentists confused about who is paying their insurance claims.
The ADA Council on Dental Benefits staff has received a handful of calls from member dentists struggling to understand the relationship between Stratose, Dental Wellness Partners, Maverest and insurance carriers like MetLife. Some of the dentists said they received incorrect reimbursements from insurance carriers or were unaware they had contracts with companies like Maverest.
Given that Stratose, formerly known as Coalition America, holds 850,000 direct and affiliate contracts with medical and dental providers nationwide and works with a dozen national and regional dental PPO networks, the confusion may be more widespread than just the dentists who contacted the ADA. Here is a primer on how a company like Stratose works:
• Stratose is a network aggregator for medical, dental and workers' compensation claims, said Dr. Roma Virani, executive vice president of Stratose's dental division. It has a network of directly contracted providers and sets up partnerships with other dental networks and offers them in an aggregated or combined fashion to anybody who pays the claims, she said. In the dental world, that's typically dental insurers or third-party administrators.
• For example, MetLife is one of the companies Stratose contracts with. A dentist who is a Maverest provider and who treats MetLife patients would be reimbursed at the fees agreed on between the dentist and Maverest. Even though the dentist never signed a contract with MetLife, their contract with a network like Maverest or Stratose allows for this arrangement.
• Dentists are usually listed on the Stratose find-a-dentist website or the Stratose client's find-a-dentist website. This helps to market the dentist's practice to members and makes it very easy for members to seek services from a participating dentist and save on out-of-pocket costs, Dr. Virani said.
"It's a positive impact on dentists' businesses," Dr. Virani said. "This model gets more patients in their office and makes the business side of things easier on them."
Members may also be referred to participating dentists if they call the Stratose client's customer service unit.
"Participating in a network helps dentists to retain and build on the loyalty with existing patients especially if they need a lot of dental work," Dr. Virani said. "Members typically do not like to change their dentist if they find someone they like and are comfortable with. However, as more of the cost may shift to the members in the future it becomes important for the patient to share in savings
• Maverest is one of Stratose's dental network partners. The Maverest network was formed through a merger of three networks: Dental Wellness Partners, Maverest Dental Alliance and the Renaissance Dental Network, Dr. Virani said.
Like a relationship with any insurance company, working with Stratose or its partners has not been without some hiccups for some dentists.
Dr. Ronald Shaskan, who practices in New York City, said he received some reimbursements from MetLife that were not accurate, given that he hadn't been a provider for the company in about 10 years. He called MetLife, which told him the reimbursements had to do with his participation in Stratose.
Dr. Shaskan said he called Stratose, which told him they had purchased Qualident, a company Dr. Shaskan said he contracted with nearly 20 years ago but thought he had discontinued the relationship. Stratose representatives told Dr. Shaskan they had a contract with him. Dr. Virani said Stratose did not receive a term notice from Dr. Shaskan until this year.
"Metlife told me I was under contract with Stratose because they took over Qualident, and they didn't have a change showing otherwise. Basically, it was up to me to prove it," Dr. Shaskan said. "We all primarily want to take care of our patients but we also have a business to run and we can't take care of our patients if we can't make our businesses successful."
Donna Pope, a business associate at Mount Airy Children's Dental Associates in Mount Airy, Md., had a similar experience. In early March, a patient questioned Ms. Pope about an explanation of benefits statement that referenced a savings with Maverest.
“Since no one in the office had heard of Maverest, we called MetLife and discovered Maverest was a company that MetLife had recently started doing business with (through Stratose),” Ms. Pope said.
Like Dr. Shaskan, Ms. Pope said Dr. David Hasson, who she works for, didn’t have a provider contract with MetLife and therefore should have been reimbursed out of network fees for any MetLife patients. But Dr. Hasson was being reimbursed at a discounted rate.
Dr. Hasson did not sign a contract with MetLife, but Ms. Pope said Maverest representatives told her the company had sent Dr. Hasson a letter stating unless he sent a letter stating he wanted to terminate his participation in Maverest or opt out of the MetLife portion of the Maverest relationship with Stratose, he would be considered a provider under Maverest.
MetLife has settled and repaid all of the money owed to Dr. Hasson’s office, he said. Maverest has deleted Dr. Hasson from any plan that listed him as a participating dental provider.
Dr. Virani said Stratose and its participating networks are committed to communicating to every dentist how the companies work together but admits there may be instances of disconnect.
“Sometimes, dentists receive a lot of different communications, and they might miss a letter from us or from a network partner,” Dr. Virani said. “They, understandably, might not pay attention to the intricacies of how Stratose works with insurance company clients until a claim is paid a certain way. As examples, a communication goes out when a Stratose client begins to access a PPO network or networks through Stratose. We had also sent a letter to the Qualident panel when Stratose acquired Qualident in 2011. In addition to the initial notification, regarding a new Stratose client, there are messages on EOBs on how claims were paid. We work with our network partners and our clients to add as much transparency to the process as we possibly can.”
The ADA’s Contract Analysis Service can help members understand their current or prospective contracts with insurance carriers. The Contract Analysis Service provides a clear, plain language explanation of contract terms and is designed to allow dentists to make informed and independent decisions on the merits of participating dentist contracts.
The service is free to members who request a review through their constituent dental society and costs $50 for members who contact the ADA directly. To learn more about the Contract Analysis Service, visit the website.